SSA-1696-APP Claimant’s Appointment of a Representative

Heading here will change to reflect the correct form
title:
"Complete Form SSA-1696 Claimant's
Appointment of a Representative"

Will change to reflect the form title:
Claimant's Appointment of a
Representative

Will change to reflect the form title:
Claimant's Appointment of a
Representative

Will change to reflect the form
title:
Claimant's Appointment of a
Representative
(same for subsequent email
images)

Will change to reflect the form
title:
Claimant's Appointment of a
Representative
(same for subsequent images)

**Note for mock-up of changes: All instructions, Paperwork Reduction Act, and
Privacy Act statements will be updated to match the revised SSA-1696. Edits
were not made in this version.
Edits to the screens begin on page 8. If the section is repeated a second time in
this screen package to show the flow of screens for the user, the edits are not
repeated throughout the document.**

On this first page,
Claimant's SSN entry
will be moved to
Section 1 Claimant's
Information and AR
Rep ID field will be
moved to new
Section 2
Representative's
Information (see
annotations below
for section changes).

As indicated on the
revised paper form, a
“Reason for
Submission”
subsection will be
added at the
beginning of this
section, requesting
that the respondent
indicate whether they
are submitting to file a
new appointment or
make an update to an
established
appointment and what
that update is

Address fields will
be removed
except zip code
(necessary for
electronic work
management
system routing).
Phone number
fields will be
removed.
Section will now
include Claimant's
SSN.

Heading will change to, Section 3 - Claimant's
Principal Representative (Claimant only - Complete
when applicable)

Instruction Language Change to:
I have appointed more than one representative. The person named below is my
principal representative. I ask SSA to make contacts or send notices to this person. Any
principal representative I named before is no longer my principal representative but is
still one of my representatives unless I have filed a separate writing revoking their
appointment.

Will be moved up after Section 1, relabel as Section 2 Representative's Information. Rep ID field wil from top
of first page will be added to this section.

Instruction Language Change to:
All representatives must register and receive a
Representative Identification (Rep ID). For more information
about registration visit us on-line at www.ssa.gov/ar, contact
us at 1-800-772-1213 (TTY 1-800-325-0778) or visit your
local Social Security office. If your representative wishes to
update their registration information, they must do so using
Form SSA-1699 Representative Registration.

Address fields
and contact info
fields will be
removed.
Rep ID field will
from top of first
page will be
added to this
section.

This heading should now read, Part A- Representative's
Status, Disqualifications or Suspensions
(Representatives must always keep this information current)

Minor changes to language in these options.

Delete heading.
Change this section to check boxes
I am now or have previously been (check all that apply):
__ Disbarred or suspended from a court or bar to which I was previously admitted to practice law.
If selected, explain: ______________________________________________________________
__ Previously been disqualified from participating in or appearing before a Federal program or agency.
If selected, explain: ______________________________________________________________
__ Removed from practice or has/had any or all my licenses suspended by a professional licensing authority or agency.
If selected, explain: _____________________________________________________________

Change heading to:
Part B - Representative's Affiliation Information

Add checkbox option for "No EIN".

Instruction Language Change to:
If you want to designate an affiliate (business, firm, or other
organization) for this claim, provide the entity's name and Employer
Identification Number (EIN) here. This number is not your Social
Security number (SSN). This number is the entity's tax identification
number. To designate an affiliate entity for this claim, you must
have already submitted to us a Form SSA-1699 that identifies
this entity as an affiliate. (If you do not want to designate an affiliate
entity for this claim, or do not qualify for or seek direct payment, mark
no EIN.)

Organization
address fields
will be removed.

Change heading to:
Part D - Representative's Certifications
Language changes to bullets:

• I understand and agree that I will comply with the applicable policy and SSA rules on the representation of parties, including
the Rules of conduct and standards of responsibility for representatives (20 CFR 404.1740-404.1799 and
416.1540-416.1599); I will not charge, collect, or retain a fee for representational services that SSA has not approved or that is
more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of applicable policy and SSA rules I may be suspended or disqualified from
acting as a representative before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or disqualified from practicing before the SSA.
• I am not prohibited from representing the claimant as a current or former officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 1 of this form in connection with the claims and
asserted rights described in Section 4 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all the information on this form and on all accompanying statements
or forms, including any information, attestations and certifications provided to SSA in registration, and that they are all
currently true and correct to the best of my knowledge.
Language will be
removed.

See prior page for other planned
edits.

** New subsection- After subsection Part B, there will be new subsection for Part C as follows:
Heading will read:
Part C - Assignment of Direct Payment of Authorized Fee to an Entity

(Complete only when applicable)

Check the Assignment box below if you want to assign direct payment of your fee to the entity you
identified above in Part B. If you previously assigned direct payment to another entity, an assignment to
a new entity in Part B also constitutes a rescission of the prior assignment. Check only the Rescission
box below if you want to rescind your prior assignment and receive direct payment with no assignment
to an entity.
[Checkbox] Assignment - I, the representative whose name appears in Section 2 and whose
signature appears in Section 8, request any fee authorized to me in this claim be directly paid to the
entity identified above in Part B. I understand that the entity to which I assign direct payment of my fee
must be registered prior to this assignment. I also understand that I can rescind this assignment only
prior to the date SSA notifies the claimant of the first favorable determination or decision. If I previously
assigned direct payment to another entity, this assignment also constitutes a rescission of the prior
assignment.
[Checkbox] Rescission of prior assignment - I, the representative whose name appears in Section 2
and whose signature appears in Section 8, rescind my prior assignment of direct payment of my
authorized fee.

See prior page for planned edits.

Move this section up to after Section 3 and change the
heading to Section 4 - Claim Type.

Change to (Check all that apply)
Change radio
buttons to check
boxes.
Change 3rd option to Claim/Appeal for Title XVI Benefits

Change heading to Section 6 - Fee
Arrangement
Language change to:
Check one box below. If the representative is eligible for direct payment and this section is left unchecked, we will
assume the representative will seek a fee, until we receive a written waiver.

Language change to options:

I will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us
to withhold a portion of the past-due benefits to directly pay the fee we may authorize. (We must authorize the fee.)
I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due
benefits, or if you do not want direct payment. You are responsible for collecting any fee we may authorize on your own.
(We must authorize the fee.)
I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual, but a
third-party entity will pay my fee. Select this box if you certify that an entity, or a Federal, state, county, or city
government agency will pay the fee and any expenses from its funds. The claimant, auxiliary beneficiaries, or other
individuals must not be liable for the fee, directly or indirectly, in whole or in part, or any expenses. (We do not need to
authorize the fee if all regulatory conditions apply.)
I waive the right to a fee.

Insert new section with heading: Section 7 - Other Claimants.
Will add Instructions:
List below any auxiliary claimants, such as a child or spouse of the claimant or number holder, who have not
appointed their own representative.

Addition of column titled, Social Security Number, and a column titled, Name. Include rows for entering
a properly formatted SSN and a text area for a name. Four rows total.

Instructional language will be added:

Both you and your representative must sign this form if you are appointing a new
representative. If you or your representative are submitting this form to update
information relating to your existing appointment of this representative:
• You must sign this form if you are updating the information in Section 3.
• Your representative must sign this form if updating the information in Section 5.
• Both you and your representative must sign this form if updating the information in
Sections 4, 6, or 7.

Will change to reflect the form
title:
Claimant's Appointment of a
Representative

Will change to reflect the form
title:
Claimant's Appointment of a
Representative

Will change to reflect the form
title:
Claimant's Appointment of a
Representative

Will change to reflect the form
title:
Claimant's Appointment of a
Representative